Table 1 Aims from the HOME occupational therapy discharge planning protocol

1. Prepare the person to return home and resume their desired lifestyle.

 a. Assess the individual person’s occupational needs respecting their personal beliefs, needs and goals and understand the older person’s patterns of daily living [26]

 b. Recommend functional adaptations that will maximise the person’s abilities as they reintegrate back to usual living [27]. The aim is for pre-admission standard of living [28]

 c. Optimise the person-environment fit [29]

 d. Recommend and implement environmental modifications

 e. Prescribe adaptive equipment and observe its use insitu [26]

2. Enhance self-efficacy beliefs and promote independence and sense of control through mastery of meaningful tasks

 1. Transfer altered skills to the home situation and assist in the adjustment to these changes [30]

 2. Habitual retraining insitu using strategies such as situational cues and targeting behaviours for change

 3. Encourage one-on-one education about the safe performance of activities in and around their home and immediate community

 4. Facilitate joint problem solving and solution generation [26, 30]

 5. Lessen a person’s fear during the transition from hospital to home [11]

3. Use goal setting as a therapeutic tool

 1. Develop client centred goals [31] that address individual occupational needs [26]

 2. Develop goals that aim to maximise the person’s potential to participate in desired activities [27]

 3. Include goals which enable the person to participate in activities both in the home and in the community [27] and incorporate health and physical activity goals [32]

 4. Plan for increasing independence/capacity over the next three months, setting goals for increasing ability [12, 14, 30]

 5. Review progress towards goals and facilitate further joint problem solving